THIEME

Original Research

Reux Laryngitis: Correlation between the

Symptoms Findings and Indirect Laryngoscopy
Carlos Eduardo Dilen da Silva1

Bruno Taccola Niedermeier1

1 Otorhinolaryngology, Universidade Federal do Estado do Rio de

Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil

Int Arch Otorhinolaryngol 2015;19:234237.

Abstract

Keywords

laryngitis
laryngoscopy
gastroesophageal
reux

Address for correspondence Carlos Eduardo Dilen da Silva, MsC,

Colegiado de Medicina, Centro Universitrio So Camilo, Rua So
Camilo de Lelis 01, Paraso, Cachoeiro de Itapemirim, ES, 29304-910,
Brazil (e-mail: cedilens@hotmail.com).

Introduction The indirect laryngoscopy has an important role in the characterization

of reux laryngitis. Although many ndings are nonspecic, some strongly suggest that
the inammation is the cause of reux.
Objective The aim of this study was to evaluate the correlation between reux
symptoms and the ndings of indirect laryngoscopy.
Methods We evaluated 27 patients with symptoms of pharyngolaryngeal reux
disease.
Results Laryngoscopy demonstrated in all patients the presence of hypertrophy of the
posterior commissure and laryngeal edema. The most frequent symptoms were the
presence of dry cough and foreign body sensation.
Conclusion There was a correlation between the ndings at laryngoscopy and
symptoms of reux.

Introduction
The term laryngopharyngeal reux disease (reux laryngitis)
was adopted in 2002 by the American Academy of Otolaryngology and Head and Neck Surgery and refers to clinical
manifestations of gastric reux on the upper airways.1,2
This supraesophageal form of gastroesophageal reux disease (GERD) was named in 1994 by Koufman and Cummins,3
not with the intention to designate the origin of reux, but to
call attention to the predominance of symptoms and changes
in the laryngopharyngeal segment.4
Estimates regarding the acid reux causing posterior
laryngitis vary widely, reaching up to 80% of cases, according
to some authors.57 This causal relationship has been fed by
the technological development of devices that are able to
measure the acidity both on proximal and distal esophagus
and the pharynx815 and also the optical bers, widely used in
clinical practice, which greatly facilitate the visualization of
the larynx.16 In this sense, indirect laryngoscopy has an
important role in the characterization of the reux laryngitis.
Although many ndings are nonspecic, some suggest that

received
September 8, 2014
accepted
December 1, 2014
published online
January 9, 2015

Fernando Portinho1

DOI http://dx.doi.org/
10.1055/s-0034-1399794.
ISSN 1809-9777.

the etiology of the inammation is the reux, such as

thickness, redness, and swelling concentrated in the posterior
parts of the larynx (posterior laryngitis).
A symptom scale (Reux Symptom Index [RSI]) was developed by Belafsky and collaborators to facilitate the suspect
diagnosis and the clinical follow-up in pharyngolaryngitis.
Patients score themselves on a scale from 0 to 5 of nine
symptoms often described of the disease (Table 1).17 Values
above 13 are considered abnormal.
In the same way, they developed a scale related to the
symptoms of reux pharyngolaryngitis, Belafsky and collaborators created a score related to the ndings of laryngoscopy (Reux Finding Score [RFS]). It consists of scores from 0 to
4 determined by the examiner of eight laryngoscopic ndings: subglottic edema, ventricular obliteration, erythema/
hyperemia, vocal fold edema, diffuse laryngeal edema, posterior commissure hypertrophy, granuloma/granulation tissue, and thick endolaryngeal mucus (8 ndings) (Table 2).
The score, which ranges from 0 (normal) to 26 (worst
possibility), indicates reux pharyngolaryngitis if greater
than 7.18,19

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234

Reflux Laryngitis

Silva et al.

235

Table 1 Reux Symptom Index

During the last month, how did the following problems affect you?

0 No problem; 5 Severe problem/very

troublesome

Hoarseness or a problem with your voice

Clearing your throat

Excess throat mucus or postnasal drip

Difculty swallowing food, liquids, or pills

Coughing after you ate or after lying down

Breathing difculties or choking episodes

Troublesome or annoying cough

Sensations of something sticking in your throat or a lump in your throat

Heartburn, chest pain, indigestion, or stomach acid coming up

Source: Belafsky et al.

19

The aim of this work is to analyze if there is a correlation

between clinical symptoms of reux pharyngolaryngitis (using the RSI) and the ndings of indirect laryngoscopy (using
the RFS) and thus detect the signs of indirect laryngoscopy
that best correlate to the main symptoms of reux laryngitis.

Materials and Methods

A survey was conducted of patients with symptoms of reux
pharyngolaryngitis at the Hospital Gaffree Guinle from August 2008 to December 2008. The following patients were
excluded from the study: smokers; people with asthma,
chronic obstructive pulmonary disease, or previous treat-

Table 2 Reux Finding Score

ment with proton pump inhibitors, antacids, or H1 inhibitors;

those with organic laryngeal disorders, previous radiotherapy, or head and neck surgeries; and psychiatric patients.20
The project was approved by the ethics committee on research (number 02/2008). All patients who agreed to participate provided informed and free consent.
We applied a symptom score (Table 1) developed by
Belafsky to facilitate the clinical diagnosis and follow-up on
DRFL (Laryngopharyngeal Reux Disease). It is scored by the
patient on a scale from 0 to 5 of nine symptoms often
described in the disease. Values above 13 are considered
abnormal. After this initial evaluation, patients had an indirect laryngoscopy exam. Belafsky and colleagues also created
a score related to the ndings of laryngoscopy (Table 2). The
score, which ranges from 0 (normal) to 26 (worst possibility),
indicates DRFL when greater than 7.19 The indirect laryngoscopy exam was performed with a rigid 70-degree ber Karl
Storz brand scope (Germany), always by the same examiner.

Subglottic edema

Absent(0)
Present (2)

Ventricular obliteration

Partial (2)
Complete (4)

Results

Erythema/hyperemia

Arytenoids only (2)

Diffuse (4)

Vocal fold edema

Mild (1)
Moderate (2)
Severe (3)
Polypoid (4)

Diffuse laryngeal edema

Mild (1)
Moderate (2)
Severe (3)
Obstructing (4)

Posterior commissure hypertrophy

Mild (1)
Moderate (2)
Severe (3)
Obstructing (4)

Granuloma/granulation tissue

Absent (0)
Present (2)

Thick endolaryngeal mucus

Absent (0)
Present (2)

From the 405 patients with symptoms of reux, 27 fullled

the criteria of this survey. The average age of patients was 54.5
years, ranging between 19 and 81. The majority of patients
were women (n 22). The laryngoscopy results revealed that
almost all patients had posterior commissure hypertrophy
(n 25; Fig. 1) and laryngeal diffuse edema (n 21). The
presence of laryngeal granuloma was not found. The average
score of reux symptoms was 17.9 (ranging from 3 to 34,
standard deviation [SD] 8.82) and the ndings regarding
indirect laryngoscopy was 5.7 (ranging from 1 to 14, SD
3.82). The most frequently found symptom was the presence
of dry cough episodes, foreign body sensation in the throat,
and clearing the throat. The patients with clinical and laryngoscopic ndings highly suggestive of DRFL received complementary therapy for the disease itself (antireux therapy
and suggestions for lifestyle changes).21
The transversal study was used, and the criteria evaluated
were mean age and sex, for symptoms of DRFL (RSI), and
indirect laryngoscopy ndings (RFS). The Pearson correlation

Source: Belafsky et al.17

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Reflux Laryngitis

Silva et al.

Fig. 1 Presence of the posterior commissure hypertrophy.

coefcient for parametric variables was used to assess the

degree of correlation, and to reject the null hypothesis,
p  0.05 was used. The software used was SPSS (Statistical
Package for the Social Science), IBM, United States, for evaluation v.14 for Windows XP, Microsoft, United States.
Analyzing the sum of symptoms of reux (RFI) and correlating these ndings to indirect laryngoscopy (RSI), a Pearson
correlation coefcient of 0.7 (strongly positive) was found, which
was statistically signicant (p  5). Correlating the main symptoms (episodes of dry cough, foreign body sensation in the
throat, feeling of cleanliness, and roughness of throat) with
the main ndings on indirect laryngoscopy, a statistically significant correlation was found only between the variables hoarseness versus subglottic edema, hoarseness versus posterior
commissure hypertrophy, and foreign body sensation versus
posterior commissure hypertrophy (bold in the Table 3).

Discussion
One of the difculties of the present study was to obtain a
larger sample of patients, especially with the indiscriminate
use of antireux medications, culminating in incomplete and
improper treatment of this disease. Another problem (or
solution) was the exclusion of any patient who had used
any tobacco in the years before the study, helping us select the
virgin larynx, free from chronic inammation.

The symptoms most frequently found were the presence of

dry cough episodes, foreign body sensation in the throat, and
throat clearing. No nding regarding indirect laryngoscopy
had a strong positive correlation to this nding. However, the
presence of foreign body sensation in the throat (globus
pharyngeus) showed a positive correlation to the posterior
third edema (posterior commissure), as well as the presence
of dysphonia (hoarseness). This region of the larynx is anatomically more prone to chronic aggression, especially after
the adoption of the supine position.
Some authors also reported dysphonia as a major symptom that is more common in the morning because of vocal
cord edema caused by night reux episodes, improving
during the day.22 A weak positive correlation (Pearson correlation coefcient close to 0) was found between hoarseness
and vocal fold edema, accepting the null correlation.
Laryngoscopy ndings demonstrated that almost all patients had the presence of laryngeal edema associated with
posterior commissure hypertrophy.
The diagnosis of reux disease as the cause of pharyngolaryngitis is not simple. Despite the evidence that favors the
association, there is no method that demonstrates unequivocally a causal relationship between Reux and Laryngitis. In
addition, endoscopy is less efcient in the diagnosis of DRFL,
because these changes are found in fewer than 20% of patients
with this disease. Vzquez de la Iglesia et al applied similar
selection criteria and exclusion surveys and found a similar
population (mostly women and patients with a mean age of
58.32),23 recommending a therapy test (empirical treatment)
in patients with symptoms highly suggestive of DRFL (score
greater than 13) and also suspicious laryngoscopic ndings
(score greater than 7), with proton pump inhibitors in full
dose for 4 months. Correlating both scores, the researchers
came to the conclusion that the laryngoscopic ndings are
most useful for diagnosis and patients symptoms are most
useful for follow-up and evolution of medical treatment.
Even after 60 years of research, both the diagnosis and
treatment of GERD and extraesophageal reux have been the
target of several studies due to their controversial nature. The
gold standard of pH monitoring on diagnosis has been
questioned by some authors, who have stated that in addition
to the test not having 100% sensitivity, the electrodes in the
digestive tract interfere with the eating habits of the patients,

Table 3 Correlation between the symptoms and the ndings on indirect laryngoscopy (statistically signicant in bold)
Subglottic
edema

Ventricular
obliteration

Erythema/
hyperemia

Posterior
commissure
hypertrophy

Thick
endolaryngeal
mucus

Granuloma
or granulation
tissue

Diffuse
laryngeal
edema

Vocal
fold
edema

Breathing difculties or
choking episodes

0.192

0.323

0.158

0.237

0.273

0.235

0.322

Hoarseness or a problem
with your voice

0.565

0.176

0.093

0.431

0.274

0.102

0.074

Excess throat mucus or

postnasal drip

0.215

0.053

0.278

0.387

0.242

0.01

0.219

Clearing your throat

0.2

0.035

0.093

0.175

0.125

0.105

0.108

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Reflux Laryngitis

Conclusion
After analyzing the data presented, we conclude that there
was a strong positive correlation between the ndings of
indirect laryngoscopy and symptoms of reux among patients who participated in the study in question; the most
common symptoms were episodes of dry cough, foreign body
sensation in the throat, and throat clearing. Furthermore,
there was a statistically signicant correlation between the
symptoms of hoarseness and foreign body sensation with the
nding of posterior commissure hypertrophy in indirect
laryngoscopy.

9 Ulualp SO, Toohill RJ, Hoffmann R, Shaker R. Pharyngeal pH

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12

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which affects the results and consequently the diagnosis.24

Other studies must establish a consensus on the diagnosis and
treatment of patients with pharyngolaryngeal reux disease
to improve the quality of life in these patients.25

Silva et al.